Because of the increased emphasis on physical fitness, knee injuries are becoming more common among athletes and the general population.
To help you understand your knee injury this booklet will cover knee anatomy, typical knee injuries, treatment choices and rehabilitation.
This booklet includes information for arthroscopy and ligament reconstruction procedures.
There are four major ligaments which support the knee:
- Anterior cruciate ligament (ACL)
- Posterior cruciate ligament (PCL)
- Medial collateral ligament (MCL)
- Lateral collateral ligament (LCL)
Two ligaments in your knee are more prone to injury, the anterior cruciate and medial collateral ligaments.
The anterior cruciate ligament (ACL) is a rope-like ligament with interwoven and overlapping fibers that act like a rope controlling the knee's movements. The ACL crosses from the back of the femur (thigh bone) to the front of the tibia (shin bone). The ACL may be injured when twisting movements (skiing) force the knee beyond its normal range of motion. You may hear or feel a "pop," experience pain, swelling or too much "play" in your knee causing your knee to buckle. A complete tear of the ACL is like the "unraveling" of rope fibers. Partial tears occur, but are less common. The medial collateral ligament (MCL) injuries are common with ACL injuries.
Orthopaedic evaluation of your knee joint is essential in determining the severity and type of injury. An evaluation includes how the injury occurred, symptoms you are now experiencing, and diagnostic tests.
Diagnostic tests may include:
- X-ray - provides views of the bones to determine if a fracture has occurred.
- Magnetic Resonance Imaging (MRI) - provides an x-ray view of ligaments and surrounding tissue
- Arthrogram - dye injected into the knee provides an outline view of tears in the ligaments and surrounding tissue damage.
What is an arthroscopy?
Arthroscopy has become one of the most frequently-used procedures for diagnosis and treatment of knee injuries. It is a minor surgical procedure that is done as an outpatient. The physician inserts the arthroscope into your knee through several small incisions. This allows the physician to see the entire knee joint and permits the repair of some injuries.
What is ligament reconstruction?
Ligament reconstruction involves replacing the torn ligament with a tendon (graft) from your knee or a synthetic material, and attaching the graft in place with screws. This procedure is performed with the use of the arthroscope. The anterior cruciate ligament (ACL) is the most common ligament requiring reconstruction procedures.
Preparing for surgery
The Department of Orthopaedics is composed of health care experts who function as a team to make your surgery a positive experience. This team includes several physicians, nurses and physical therapists who will provide you and your family with information about treatment options and guide you through the phases of the treatment you choose.
You will receive a letter to come to the Orthopaedic Clinic a few days before your surgery. If you are under 18 years of age, your parent or guardian must come with you to sign your operative permit. Please be prepared to inform the physician of any drug allergies or sensitivities. Also, please inform the physician of any medications that you are routinely taking. The preparation for surgery (work-up day) includes:
- Nursing assessment and pre-op and post-op instructions
- Physical exam and health history
- Discussion with physician about the procedure, risks and benefits and signing informed consent for the procedure
- Consult with anesthesiologist (physician who puts you to sleep)
- Meet with physical therapist (instructs you on exercises and crutch ambulating and may fit you with a knee brace)
Reasons to notify your physician:
Changes in your general health will affect your surgery. If at anytime prior to your surgery any of the following conditions develop, please notify your physician.
- Symptoms of cold
- Fever and/or chills
- Irritation of eyes, ears, throat or gums, and any dental problems
- Boils, or skin abrasions or cuts
- Stomach or intestinal illness such as, diarrhea, nausea and vomiting or blood in stool
- Kidney or bladder changes that include burning with urinating, blood or pus in your urine and needing to urinate more often or an urgent sensation when urinating
- If there is any possibility that you may be pregnant
It is very important that you observe the following instructions:
- Do not eat or drink anything after midnight unless otherwise instructed by your physician or the anesthesiologist. Your surgery may be canceled if you eat or drink after midnight or as instructed.
- On the night before surgery and again the morning of surgery, you need to scrub your knee for five minutes with soap-filled sponges you received from the nurses. You will receive the sponges the day of your work-up visit. If you are allergic to iodine or to soaps please report this to the medical staff.
- Take routine medications only as directed by your anesthesiologist or physician.
- Remove all nail polish and do not wear make-up the day of surgery.
- Leave all jewelry, money, watches and valuables with family. The hospital can not be responsible for your valuables.
- Wear comfortable, casual clothing that is easy to get on and off (drawstring-style sweat pants, boxer-style shorts or loose clothing). There will be a locker available for your clothing while you are in surgery.
- If you have crutches, a knee immobilizer or a brace, please bring them to the hospital the day of surgery. You may need these after surgery.
- You may wish to bring reading material or crossword puzzles to occupy your time while you are in the hospital.
- Arrange to have an adult (someone over 18) available to drive you home after discharge, and have someone stay with you at least 24 hours once you are home. You will not be allowed to leave the hospital alone.
- The day before surgery call the presurgical work-up facility between 8:30 a.m. and 4:30 p.m. at 353-7702 to obtain your check-in time for the day of surgery.
Day of surgery
Upon arrival at the hospital, please report to the pre-surgical work-up facility (the same area in which you saw the anesthesiologist), take elevator H to the 5th floor and turn right off the elevators.
You will be asked to change into a hospital gown and bikini pants, remove jewelry and contacts. (We suggest you leave your contacts out the day of surgery.) The nurses will check your pulse, blood pressure and temperature, and ask you a few questions. Once this is completed, you will be directed to a waiting area until the operating room noifies the nurses. You will then be taken to the operating room on a cart. The anesthesiologist talks with you briefly, an IV (needle inserted to give you fluids) is inserted, and final preparations are carried out.
Your family will be directed to waiting rooms. Medical staff will notify them when your procedure is completed, and how you are doing. They will be directed to the appropriate area once you have completed your recovery room stay.
When surgery is completed, you will be taken to the recovery room. The usual length of stay in the recovery room is 1 hour, but may be longer according to the surgical procedure and the type of anesthesia.
While you are in the recovery room, the nurses will be checking your blood pressure, pulse, respirations and temperature frequently. They will also be checking the sensation and circulation in your surgical leg.
You may have a large bandage, a brace or an ice cuff on your knee.
After your stay in the recovery room you will be transferred to an inpatient floor. Nursing staff will continue to monitor your recovery, provide medication for pain and/or nausea, and give ice chips and liquids. During this final recovery stage, your nurses review homegoing instructions, obtain prescriptions and you may be seen by a physical therapist.
Discharge is based upon your recovery from the effects of anesthesia, and if your pain is under control. Your physician determines if you are ready for discharge. If additional observation is required, you may be admitted to the hospital.
What Happens at Home?
It is normal to feel drowsy for 24-48 hours after surgery and to require pain medication at regular intervals. These symptoms will gradually subside and each day you will feel less sleepy and painful.
- Crutches are used for a short time. Put only as much weight on your surgical leg as advised by your physician.
- Always wear your brace when walking, or as instructed by your physician.
- Daily knee exercises are important for the return of a functional and healthy knee.
- Keep your wound and bandage clean and dry. Change and remove bandage as instructed.
- Your wound should not come in contact with water. Change any bandage immediately if it becomes wet or bloody.
- You may shower with a plastic bag securely taped beyond the upper edge of your brace. It is recommended to sit on a chair in the shower, keeping your bandaged leg out of the direct water spray.
- Applying ice for the first 24-48 hours after surgery will reduce pain and swelling.
- Elevating your leg above heart level as much as possible will also reduce pain and swelling.
- Elevate your leg after exercises and always at night, with your knee above heart level.
- Take pain medication as prescribed. Do not drink alcohol when you are taking this medication. Take medication 30 minutes before exercises.
- Eventually pain subsides and Tylenol should control your pain.
A physical therapist will instruct you on crutch ambulation, range of motion and strengthening exercises. Continuing these exercises after your surgery is important to maintain knee range of motion, reduce scar tissue and strengthen weakened muscles. Your physician will specify when you should begin an exercise program to gain motion and/or to strengthen muscles above your knee. Two commonly used exercises are quadriceps setting and straight leg raises.
Lie on your back with your knees straight, legs flat and arms by your side. Tighten the muscles on the top of the thigh (quadriceps), and at the same time push the back of the knee down into the table and raise only the heel. Hold for 5 seconds, relax 5 seconds. Repeat this exercise 6 times on a firm surface at least 4 times a day.
Straight leg raising
Lie on your back with your operative knee flat and straight. Keep the other leg bent with foot flat on the floor. Slowly raise your operative leg about 6 inches off the floor, keeping the leg as straight as you can. Hold for a count of 5 seconds, then lower the leg. Repeat this exercise 6 times on a firm surface at least 4 times a day.
Follow-up visits are necessary for your doctor to chart progress, change bandages, check for any complications and evaluate your rehabilitation progress.
If the following occurs:
- Swelling, tingling, pain or numbness in your toes which is not relieved by elevating your knee above heart level for 1 hour
- Drainage that is foul smelling, green or yellow, or drainage where there was none before
- Chills or temperature above 38.5° C (101.3° F). or if greater than 38° C (100.4° F) for 24 hours.
Contact the Orthopaedic clinic nurses at 319-356-3844 Monday through Friday (8:00 a.m. to 5:00 p.m.). After 5:00 p.m. and on weekends or holidays call 319-356-1616 and ask for the Orthopaedic physician on call.
University of Iowa Department of Orthopaedics